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Primary Nonoperative Treatment of Displaced Lateral Fractures of the Clavicle
C. Michael Robinson, BMedSci, FRCSEd(Orth)1; David A. Cairns, MRCSEd1
1 Shoulder Injury Clinic, Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh EH16 4SU, Scotland. E-mail address for C.M. Robinson: c.mike.robinson@ed.ac.uk
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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, Scotland

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Apr 01;86(4):778-782
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Background: The optimal management of displaced fractures of the lateral end of the clavicle remains controversial. Successful results have been reported both with primary open reduction and internal fixation and with nonoperative treatment. The purpose of this study was to analyze the results of employing a policy of primary nonoperative treatment of displaced lateral fractures of the clavicle.

Methods: We treated a cohort of 127 patients who had sustained a displaced fracture of the lateral end of the clavicle. With the exception of seven patients who had immediate internal fixation, all of these patients were treated nonoperatively. At the time of follow-up, nineteen patients had died or could not be traced and fifteen were interviewed by telephone only. The remaining eighty-six patients were assessed clinically at an average of 6.2 years after the injury. All of these patients had a functional evaluation and were assessed radiographically.

Results: Fourteen (14%) of the 101 patients who could be contacted had had symptoms severe enough to warrant delayed surgical intervention (Group I). The remaining eighty-seven patients had not undergone any surgery, and twenty-one of them (21% of the whole cohort) had a nonunion of the clavicular fracture. The average Constant score in the nonoperatively treated group was 93 points (range, 82 to 98 points). With the numbers available, there was no significant difference in the Constant or Short Form-36 (SF-36) scores between the patients with nonunion (Group II) and those in whom the fracture had healed (Group III) or between the patients who had been treated nonoperatively (Groups II and III) and those who had had delayed surgery (Group I). There was no significant difference between the SF-36 scores in any of the groups and the scores for age-matched controls in the general population.

Conclusions: Nonoperative treatment of most displaced lateral fractures of the clavicle in middle-aged and elderly patients achieves a good medium-term functional result. Symptoms that were severe enough to warrant a delayed reconstructive procedure developed in only 14% of the patients. Asymptomatic nonunion does not appear to adversely affect the functional outcome in the medium term.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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